A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
Monitor the client's temperature once every 6 hr.
Wear an N95 respirator when providing direct client care.
Make sure dietary plates and utensils are disposable.
Make sure the client's room has positive-pressure airflow.
The Correct Answer is D
A. Clients in protective isolation require more frequent temperature monitoring due to their high risk for infection. Monitoring once every 6 hours may not be sufficient to detect early signs of infection.
B. An N95 respirator is necessary for airborne precautions (e.g., tuberculosis) but is not required for protective isolation unless indicated for another reason.
C. While disposable plates and utensils may be used, they are not a primary requirement for infection prevention in protective isolation. Properly cleaned and sanitized utensils are generally safe.
D. Protective isolation requires positive-pressure airflow to prevent airborne pathogens from entering the client’s room, reducing the risk of infection in immunocompromised individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Applying medicated powder under the vest is not recommended as it can interfere with the fit of the device, cause skin irritation, or affect the traction. The nurse should avoid using powders or lotions in the area.
B. The nurse should not loosen or tighten the screws on the halo traction device, as this requires a healthcare provider with the appropriate expertise to adjust it. Any adjustments should be made by the physician or specialist.
C. Ensuring that there is space for one finger between the vest and the client's skin is important for preventing skin breakdown and ensuring proper fit of the device. The vest should be snug but not tight enough to cause discomfort or pressure.
D. The nurse should not move the client by holding onto the halo traction device, as this can cause injury or disrupt the device's alignment. Instead, the nurse should use proper techniques and support to move the client safely.
Correct Answer is A
Explanation
A. Humidified oxygen is an essential intervention for a client with flail chest. Flail chest occurs when multiple rib fractures result in a segment of the chest wall that moves independently during breathing. This leads to respiratory distress, and providing humidified oxygen helps improve oxygenation and reduce airway irritation.
B. Fluid restriction is not indicated for flail chest unless there is another specific condition (e.g., heart failure) that requires it. The primary concern in flail chest is respiratory support, not fluid management.
C. While acetaminophen may be used for pain management, it is not the priority in managing flail chest. Pain control is important, but the focus should be on ensuring adequate ventilation and oxygenation.
D. Antibiotic medication is not indicated unless there is evidence of infection, such as pneumonia. Flail chest itself does not require antibiotics unless there are associated complications like a chest infection.
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